3236 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
• %JILDINCZ PROJECT IDENTIFICATION E UMBER
SOILDING APPLICATION & PERMIT
•DD1E59 ",, J
2316
DOII t �cCl/ ILL LJD BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S ( /," PLAN CHECK VALIDATION
NAME " \'�` ) TV. ELECTRIC PERMIT FEE
z>0A) kv &4-�c ONE 97 ."3s
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
�eAL-P'll -n/ LIC.NO. LIGHTING FIXTURES 5.00/1.00 ,
CONTRACTORS
AONTRAS PPLIANCES-RESIDENTIAL 4.00
C
PHONE PANELS 5.00 DATE OF APPLICATION
AARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
N� LIC.NN. SIGNS TRANS. 3.00
ARCH OR ENO-A+ SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
A zlP EMP.METER OR POLE INS. 15.00 eo9
APPr
LncCNs
ADMOTORS SEE FEE SCH.
DREss
Q / gd / SERVICE CHANGE 10.00 �iJI 4w
o
, 00 LICENSED CONTRACTORS DECLARATION
w
a o u I hereby uflirm that 1 am license) tinder Provisions of Chapter 9SUANCE DATE
v,rt ea (cotmmenc Eng with Section 7000)of Division 3 of the Bei mess and SLOG_ ELECT. PLG. MECH.
F D z Professions Code,and my licenw x in full force and effect. ❑ ❑ El
0 License Class Lie.Number
I. o DateContractor
a y ILDING PERMIT
Siro: a a OwwiR-nuaDliR necl.n RATION NFORMATION
F
m I hereby aIfrm that I am exempt from the Contractors License MISC:- REFER TO ORD
F .. o f Law for the following reason.(Sec.7031.5.Busine,sand Professions PERMIT ISSUANCE 600 5/FT.
Code:Any city or county which requiresa permit to conslruct'.11".
2 2 ¢ p improve,demolish,or repair any structure,prior to its issuance-also ELEC.CONTR. LIC.NO. ELEC. /V
K O u requires the applicant for,such permit to file a signed stalemem that - TOTAL
K
he is licensed pursuant to the previsions of IhC Contractor's 3 ocnu TTO
O _r
Hivit
> Low(Chapter 9(mmmencingwith Section 7000)ofDivisiun3oflhe ///�A,/II///.��f��^^rll�� '
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ac _ $ the basis for the alleged exempliun.Any violation cf Seclinn 7031.5 STORIES TYPE CONSTR.
d by any applicant fore permit dollars
the applicant tau civil Penalty ALTER-DRAIN VENT-WATER (EA.) 4.00
of not more than five hundred dollars the 1J:
❑ L,as Owner Of the Properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec, 7044. Business and Professions DRAINS-FLOOR, ROOF,AREA,CONN. 4.00
Code:The Contractor's License Law docs not apply m an owner or -
propertywhobuildsorimprovesthereon.and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTALACREAGE
Norris re of rote his own employees.Provided that such improve-
mems are not intended or n ffered for employees,pre.ovided
that such
he buildiimprove-
Norris GAS-EA.SYSTEM-1 1NC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner. GAS EA.SYSTEM OVER 4 (EA) 1.00 Bu1LOING usE
builder will 1,,,,th
ve e burden of proving that h - - .
e did not build or int- RES IND CO PB Otner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 AS ESSORS ARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 Jye-. -�
Contracts for such projects with a contractodsu
sl licensed purant to
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4,00 014&
4K 4W
reasonrealc�ha�y/v v' Ow'nef WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO,
WORK ERS'C011PENSATION DECLARATION WATER TREATING EQUIP, 4.00 ^-
m -�-
hereby affirm that I have a certificate of consent to sel Ginsure. - ONIN ENG.SITE NO.
or certificate of Workeri Compensation Insurance,or a certified - Z//
Copy thereof(Sec.3800,LAC.),
Policy No. Company ll�s. l7
O ❑ Certified Copy is hereby furnished. FIRE PRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y� N❑ y ❑
CCN CERTIFICATE OF EXENIPTION PROAL WORKERS* PERMIT ISSUANCE 6.00 FLOOD ZONE -
W �_ CO.IPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ `�
CL 0 (This section need not be completed if Lha permit is for one TOTAL
z:) 2 hundred dollars(S 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is iswed,1 shall not employ any person in any manner so as to
O w become Subject to lire Workers'Compensation Laws of California.
a Dale Applicant ALTER OR ADD TO MECH.- 4.00 BUILDING 7-r.5-j
} N NOTICE 10 APPLICANT: It,after making This Certificate of Fix-
? emption,you should become subject to the Workers'Compensation - APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEEO 5W3
U such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10)100 C-F.M.) 3.00 cl�l
CONSI'RUCTION LENDING AGI7NCY AIR HANDLING UNIT(OVER 10p00QF.M.) 5.00 SEISMIC FEE 15'6
I hereby affirm that there is a construction lending agenev for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,ON C.) HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lander',Name H EATI NG UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 -
information n correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating m building l city anion. and BOILER-COMPO H.P.or 100,000 B.T.U.) 4.00
hereby autfionic representatives of this city to enter upon the
bove-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
a
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may I ny way accrue gai t said City in consccpm o cc of the
granI Ibis pemlil MECH.CONT. LIC.N0. MECH. /3
/ _i"/� ✓�� .3l /97 TOTAL TOTAL �.3
/� /S�igLnall u�rr;o f Xppf DContoufor rC�Uiic
OFFICE COPY
CITY 017 GUPERTLNO INSUCTIOL RECORD (Office Copy)
3236 10011 N. Foothill_Blvd._
PEPill-1' N0. SANITARY DIST. NO. LOT NO ADDRESS
Interior Imp. Don L. Beck
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
BuQdins' _ 316-83 Date Insp .
Electrical Power Pole
PlumhLnv Under ground
ticchanical RouF;h Wiring
'Temp. Gas/I;iecL. Ila-IIs
Solar Ceilin
Fire Sprinkler Fixtures Int/Ext
SiSn Motors
Grounding
Misc. Temp. Power _
Other
FINAL INSPECTIONS Not Approved _
Date Insp.
Grs
— PLUMBING
Electric Date Insp.
Plumbing Backflow
!lechanical Underground
Solar Underfloor
Pool Partial Rough
Gradin , Rough Complete
Planning Solar Rough
Fire Dept. Water & Insulation
Health Dept. *fain Drain
Building R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation
Da Ce Insp.
Pre-Gunite
Underfloor S.H.
Slab-Ilembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace _ _
Floor Steel Grease Duct & hood
Tiedowns One Hour Shaft _
D.i.aphrams Condensate Drain
Seismic Bracing; Equipment Anchorage
I lal.ls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Uallboards Int/Ext.
Firewalls
Other
ONot AEproved